Medicare AdvantagePrior AuthMedium impact
MA08.161d, Retifanlimab-dlwr (Zynyz®)
Independence Blue Cross·Pharmacy, Oncology·Pharmacy
Effective date
May 4, 2026
We identified it
Jun 19, 2026
Summary
Policy MA08.161d establishes medical necessity criteria for Retifanlimab-dlwr (Zynyz®), a new immunotherapy drug. This is a pharmacy policy affecting Medicare Advantage plans, requiring billing and prior authorization teams to understand coverage requirements before dispensing or billing this medication.
Action Required
By May 4, 2026: Pharmacy and billing teams must review the full medical necessity criteria in policy MA08.161d at the provided URL and implement prior authorization requirements for Retifanlimab-dlwr (Zynyz®) claims. Update pharmacy billing software and prior auth workflows to enforce the medical necessity criteria outlined in this policy. Coordinate with providers and pharmacies to ensure they understand coverage requirements before dispensing. Obtain prior authorization from the Medicare Advantage plan before billing claims for this medication, or claims will be denied. Reference the full policy text at https://medpolicy.ibx.com/ibc/ma/Pages/Site-Activity-View.aspx?FilterField1=MPSiteActivityLogMonth&FilterValue1=05&FilterField2=MPSiteActivityLogYear&FilterValue2=2026 for complete medical necessity criteria.